Cases/Maternity and Reproductive Health

Widespread Itching Worse At Night — Free SCA Practice Case

Pregnant woman with widespread itching worse at night

Station Timer

12:00

Golden Minute

Initial Introduction

•Introduce yourself

•Ask an open question — "How can I help you today?"

•Listen — don't interrupt

•Catch early cues

Data Gathering

History, ICE & Diagnosis

Clinical Management

Diagnosis, Plan & Decisions

Safety Net

Follow-up & Close

12:00

Golden Minute

Materials for Candidate

Please review before starting the consultation

Patient Profile

Full Name

Amara Okonkwo

Age

30 years

Consultation Type

Telephone

Age

Situation

Telephone Consultation. The patient has booked an urgent telephone appointment.

Reason for Encounter

"Doctor, I want something for my itching — I've been itching all over and it's getting really uncomfortable, especially at night."

Medical Records

●PMH: Nil significant. Gravida 1, para 0. Currently 33 weeks pregnant.
●Medications: Nil.
●Allergies: NKDA.
●Recent notes: Pregnancy uneventful; up to date with midwife appointments.

Patient Script

For the friend playing the patient role

Character Overview: You are Amara, a 30-year-old woman, 33 weeks pregnant with your first child. You have developed widespread itching over the past two days, worse at night and disturbing your sleep. Moisturisers have not helped. You have no rash. You feel well otherwise and the baby is moving normally. You are due to fly abroad on holiday tomorrow and are keen for something to settle the itch so it does not spoil your trip. You are pleasant and cooperative and will accept what the doctor advises.

Opening Sentence: "Hi Doctor. I'd like something for this itching, please. I've been itching all over for the last couple of days — it's worse at night and keeping me awake. Moisturiser isn't touching it. I'm 33 weeks pregnant and I'm meant to be flying off on holiday tomorrow, so I really want to get it sorted."

History if Asked (Data Gathering Phase)

●The itch: "It's all over — not one particular spot. It started about two days ago and it's getting worse, especially at night. It's really disturbing my sleep."
●Rash: "No rash at all — that's the odd thing. Just the itching, but my skin looks normal."
●What she's tried: "Just moisturiser, which hasn't helped."
●The pregnancy: "First pregnancy, 33 weeks, all been fine so far. Baby's moving normally, I'm up to date with the midwife."
●The holiday: "We're flying abroad tomorrow for a week. I've been looking forward to it — I just want the itch sorted so it doesn't ruin it."

ICE — Ideas, Concerns, Expectations

The patient does not volunteer this information unprompted. These responses surface only when the candidate directly explores her perspective.

●Ideas: Amara has heard that itching is common in pregnancy and assumes it is nothing serious — just a nuisance to be treated. "I just assumed itching is one of those normal pregnancy things — annoying but harmless."
●Concerns: Her concern is mainly that the itching is affecting her sleep and might spoil her holiday; she is not aware it could signify anything serious. "Honestly, my worry is my sleep and the holiday — I hadn't thought it could be something to worry about."
●Expectations: She wants a safe medication to stop the itch so she can travel and sleep. "I was hoping you'd prescribe something safe to stop the itching so I can enjoy the trip."

If Asked — Medical History

The patient confirms these details only when directly asked.

●Obstetric history: "First pregnancy, no problems until now."
●Medications: "Nothing — no tablets, no new creams or products."
●Skin conditions: "No eczema or skin problems normally."
●Allergies: "None."
●Social: "I work as a nail technician, non-smoker, I don't drink, especially not now I'm pregnant. My husband's very supportive."

If Asked — Cholestasis and Differential Screen

The patient answers these only when directly asked.

●If asked about whether the itch is localised or generalised: "Generalised — all over, not one place."
●If asked, specifically, about itching of the palms and soles: "Yes, actually — my palms and the soles of my feet are itchy too." (A pointer to obstetric cholestasis.)
●If asked about rash: "No rash anywhere."
●If asked about worse at night: "Definitely worse at night — it's keeping me awake."
●If asked about jaundice, dark urine, pale stools: "No yellowing, my urine and stools seem normal."
●If asked about right-upper-abdominal pain, nausea, malaise: "No tummy pain, no real nausea, just a bit tired from not sleeping."
●If asked about contact with anyone else itching (scabies): "No, no one else is itching, and it's not in the skin folds or between my fingers particularly."
●If asked about triggers (heat, hot showers): "Not really — it's there most of the time, worse at night."
●If asked about medications that cause itch (e.g. opioids): "No, I'm not taking anything."
●If asked about fetal movements: "Yes, baby's moving normally."
●If asked about red flags (weight loss, night sweats, lumps): "No weight loss, no night sweats, no lumps."

Responses to Management (The Negotiation Phase)

●If the Doctor explains the itch could indicate obstetric cholestasis and needs urgent assessment: "Obstetric cholestasis? I thought itching was just a normal pregnancy thing. Is it serious?" (The tested point is explaining, without excessive alarm, that generalised itching without a rash in later pregnancy needs urgent blood tests to rule out a liver condition that can affect the baby.)
●If the Doctor arranges same-day maternity assessment: "Today? But I've got so much to do before the holiday. Can't you just give me something?" (The tested point is arranging same-day assessment for bloods and fetal monitoring rather than simply prescribing.)
●If the Doctor advises against travelling tomorrow: "You're saying I shouldn't go on holiday? We've paid for it and I've been looking forward to it." (The tested point is clearly advising against travel until assessed, sensitively, and mentioning travel insurance.)
●If the Doctor discusses what happens if tests are normal: "And if the tests are fine — can I have something for the itch then?"
●If the Doctor safety-nets: "What should I watch out for before I'm seen?"

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 16 indicators checked+0−0

Positive (0/8)

Negative (0/8)

Domain 2: Clinical Management and Medical Complexity

0 / 18 indicators checked+0−0

Positive (0/9)

Negative (0/9)

Domain 3: Relating to Others

0 / 12 indicators checked+0−0

Positive (0/6)

Negative (0/6)

Clinical Learning Points

Itching in Pregnancy — A Differential, Not a Given

●Itching in pregnancy may be due to a pre-existing skin condition, a pregnancy-specific cause, or something unrelated (eczema, allergy, scabies). A focused history and the presence or absence of a rash guide the diagnosis.

Obstetric Cholestasis (Intrahepatic Cholestasis of Pregnancy)

●Typically causes generalised itching without a rash, often worse at night and frequently involving the palms and soles, usually in the later part of pregnancy (after ~28 weeks).
●It reflects impaired clearance of bile acids and is associated with risks to the baby — hence the need for urgent blood tests (liver function and bile acids) and fetal monitoring.

Rash-Associated Pregnancy Eruptions

●Polymorphic eruption of pregnancy, atopic eruption of pregnancy, and pemphigoid gestationis usually present with itching accompanied by a rash, often starting on the abdomen — distinguishing them from obstetric cholestasis.

Assessment and Same-Day Referral

●Generalised itching without a rash in later pregnancy warrants same-day assessment at the maternity/day assessment unit for urgent LFTs and bile acids and fetal wellbeing monitoring — not a phone prescription.
●Always check fetal movements in any later-pregnancy contact.

Management of Confirmed Obstetric Cholestasis

●If confirmed, care is individualised: serial monitoring of LFTs and bile acids, consideration of the timing of delivery according to severity and gestation, and ursodeoxycholic acid (used to relieve itch and reduce bile acids). Management is consultant-led in secondary care.

Symptomatic Relief (After Excluding Cholestasis)

●If investigations are normal, symptomatic measures include menthol 0.5–1% in aqueous cream and a sedating antihistamine at night (e.g. chlorphenamine) to aid sleep — noting off-label use in pregnancy — but only after cholestasis is excluded.

Advising Against Travel

●Advise clearly and sensitively against travelling until assessment is complete and it is safe; mention that a travel-insurance claim may be possible given the medical advice.

Common Candidate Mistakes in This Case

●Dismissing it as normal pregnancy itch: offering a prescription without recognising possible obstetric cholestasis — the key error.
●Not arranging same-day bloods/assessment: managing over the phone rather than arranging urgent LFTs, bile acids, and fetal monitoring.
●Failing to advise against travel: letting her fly the next day before assessment.
●Missing discriminating features: not asking about palms/soles, night-time pattern, or the absence of a rash.
●Weak safety-netting: not covering reduced fetal movements and cholestasis warning signs.

Free MRCGP SCA practice case for GP registrars covering Widespread Itching Worse At Night — Maternity and Reproductive Health. Includes candidate brief, patient script, marking scheme mapped to the RCGP SCA marking domains, and learning points. Built directly from the RCGP curriculum topic stations listed under "How this might be tested in the MRCGP SCA," part of a free library of 79 SCA practice cases for simulated consultation assessment preparation.

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